Obstetrics Flashcards
What is premature labour? (gestational age)
24 completed weeks - 36 weeks + 6 days
What are the risk factors for premature labour?
Low socioeconomic status Maternal age (<20 and >35) Genital tract infections PPROM APH Cervical incompetence Congenital uterine abnormalities DM Antiphospholipid syndrome Smoking and substance abuse Previous preterm delivery
How is premature labour diagnosed?
Pregnant women may present with a history of painful contraction and assume they’re in premature labour. Many of these women are experiencing Braxton Hicks contractions.
What are the important questions to ask when taking a history for premature labour?
Duration of contractions and interval bleeding or fluid loss
Full obstetric history
What may be seen on examination for premature labour?
Speculum examination may reveal a dilated cervix and/or amniotic fluid leak
Digital examination should NOT be performed if the membranes have been ruptured due to risk of infection.
If the membranes are intact, a digital examination is the best way of assessing premature labour.
What is the management for premature labour?
Transport pregnant mother to safest facility for delivery
Tocolytic drugs: nifedipine, atosiban (oxytocin receptor antagonist)
Corticosteroids: If mother is 24+0 - 35+6 weeks
Magnesium sulphate for neuroprotection: 24+0 - 29+6, consider for 30+0 - 33+6
Emergency cervical cerclage: 16+0 - 34+0 who have a dilated cervix and unruptured membranes
What is PPROM?
Premature prelabour rupture of membranes
It is the rupture of membranes prior to the onset of labour in a patient who is <37/40.
What is PROM?
It refers to the rupture of membranes occurring prior to the onset of labour and can occur from 37+0 weeks onwards
What are the risk factors for PPROM?
Smoking
Previous preterm delivery
Vaginal bleeding at any time in the pregnancy
Lower genital tract infection
What is the presentation of PPROM?
A history of a “popping sensation” or “gush” with continuous watery liquid draining thereafter. Underwear or pad may be damp.
What investigation would you perform for suspected PPROM?
DO NOT routinely perform a digital examination.
Seeing amniotic fluid draining from the cervix and pooling in the vagina after lying down for 30 minutes is the most accurate test.
USS to check gestation and liquor volume
Temperature monitoring
Foetal monitoring
What is the management for PPROM?
Refer urgently to hospital
Prophylactic antibiotics
Antenatal steroids if between 24+0 and 34+6
Delivery or expectant management
What is the aetiology of miscarriage?
Genetic abnormalities Endocrine factors Maternal illness and infection Abnormal foetal development Uterine abnormalities Incompetent cervix Placental failure Multiple pregnancy PCOS Antiphospholipid syndrome Inherited thrombophilias Poorly controlled DM Poorly controlled thyroid disease
What are the different types of miscarriage?
Threatened miscarriage Inevitable miscarriage Incomplete miscarriage Complete miscarriage Missed miscarriage Recurrent miscarriage (>/= 3)
What are the risk factors for miscarriage?
Maternal age (>30) Smoking Excess alcohol Low pre-pregnancy BMI Paternal age Fertility problems Illicit drug use Uterine surgery/abnormalities Connective tissue disorders Uncontrolled DM Being stressed/anxious
What is the presentation of a miscarriage?
PV bleeding and pain worse than a period
+/- products of conception
What is the differential diagnosis of a miscarriage?
Ectopic pregnancy Implantation bleed Cervical polyp Cervical ectropian Cervicitis/vaginitis Neoplasia Hydatid mole
What investigations would you perform for a suspected miscarriage?
USS (usually transvaginal) Serum hCG (progesterone)
What is the management for a miscarriage?
Access to support, follow up and counselling.
Conservative: urine pregnancy test at 7-14 days and watchful wait
Medical: vaginal misoprostol and a pregnancy test 3 weeks after receiving treatment
Surgical: Vacuum aspiration
What are the risk factors for gestational diabetes?
>35 years old BMI >30 Smoking Previous stillbirth Previous large baby (>4.5 kg) Previous GDM FHx of T2DM More common in Asian, Middle Eastern and African women
What is the pathology of gestational diabetes?
Maternal insulin sensitivity decreases in pregnancy due to human placental lactogen to increase blood glucose to provide enough glucose to the foetus, especially in the 3rd trimester.
How is gestational diabetes usually diagnosed?
Diagnosis is not easy so screening is used for at risk patients as they’re often asymptomatic.
What are the risks of GDM?
Macrosomia Shoulder dystocia Foetal jaundice Congenital defects Increased risk of T2DM late in life Increased risk of childhood obesity Increased risk of tears in the mother T2DM in mother - 50% at 15 years and 50% at 5 years if they required insulin. Increased risk of still birth
What investigation would you perform for GDM?
A 2 hour 75g OGTT
Screening takes place of all mothers with known risk factors at 24-28 weeks gestation
What is the classification of GDM?
A1 - abnormal OGTT but normal glucose levels fasting + at 2 hours
A2 - abnormal OGTT and high glucose levels during fasting and at 2 hours
What is the management for GDM?
Diet control and exercise (usually A1)
Metformin
Insulin
What are the risk factors for pre-eclampsia and eclampsia?
Primigravida FHx of pre-eclampsia Previous pre-eclampsia <155cm maternal height BMI >/= 35 at presentation Maternal age <20 or >35 History of migraine, hypertension, renal disease Multiple pregnancy
What is the aetiology of pre-eclampsia and eclampsia?
Suboptimal uteroplacental perfusion associated with a maternal inflammatory response and maternal vascular endothelial dysfunction leading to vascular hyperpermeability, thrombophilia and hypertension. May compensate for decreased flow in uterine arteries.
What are the signs and symptoms of pre-eclampsia and eclampsia?
Flu-like symptoms Vomiting Tachycardia Hyperreflexia and clonus Seizures (eclampsia) Headache Visual disturbance Bruising (platelets <100) Epigastric pain Increased urea and creatinine Abnormal LFTs Papilloedema Foetal distress
How is pre-eclampsia or eclampsia diagnosed?
Systolic >140 mmHg or diastolic >90 mmHg in the second half of pregnancy AND >/= 1+ proteinuria on a dipstick
What investigations would you perform for pre-eclampsia or eclampsia?
Urinalysis
Frequent monitoring of FBC, LFTs, renal function, U&E
Foetal USS
What is the management of pre-eclampsia/eclampsia?
Patients can usually be managed conservatively until at least 34/40 as long as they’re haemodynamically stable and without coagulopathy or HELLP.
Delivery of the placenta is the only cure for pre-eclampsia but the risk of pre-eclampsia still exists for approx 1 week after delivery.
If <34/40 give corticosteroids
What is placenta accreta?
The chorionic villi penetrate the decidua basalis to attach to the myometrium
What is placenta increta?
The chorionic villi penetrate deeply into the myometrium
What is placenta percreta?
The chorionic villi breach the myometrium into the peritoneum
What are the risk factors for placenta accreta/increta/percreta?
Previous C section
Placenta praevia
Advanced maternal age
What investigations would you perform for placenta accreta/increta/percreta?
It is usually diagnosed through foetal USS at 20 weeks
MRI
What is the management for placenta accreta/increta/percreta?
Consultant obstetrician and anaesthetist at delivery
Elective C-section at 36-37 weeks
Blood and blood products available
MDT involvement in pre-op planning
Discussion and consent including hysterectomy
Leaving the placenta in place
Cell salvage
Interventional radiology
Local availability of level 2 critical care bed
What is the classification for placenta praevia?
Major: the placenta covers the internal os of the cervix
Minor: if the leading edge of the placenta is in the lower segment of the uterus not does not cover the os
What are the risk factors for placenta praevia?
Previous placenta praevia Previous C-section Advancing maternal age Increasing parity Smoking Cocaine use during pregnancy Previous spontaneous or induced abortion Deficient endometrium due to endometritis Manual removal of placenta Curretage Assisted conception
What is the presentation for placenta praevia?
It is often an incidental finding on routine USS
Painless bleeding after 28/40
How is placenta praevia diagnosed?
Clinical suspicion should be high in any woman with PV bleeding after 20/40
Transvaginal USS - USS can’t exclude placental abruption as it’s a clinical diagnosis
Placenta may be low at 20/40 USS but appear to “migrate” due to development of the lower uterine segment so monitor these women
What is the management for placenta praevia?
A woman with minor placenta praevia may be able to deliver vaginally, if <2cm away from the os then requires a c-section
Major: delivery by C-section and avoid penetrative intercourse
What are the different types of placental abruptions?
Concealed (20%) - more severe, blood loss is easily underestimated
Revealed (80%) - blood drains through the cervix
What are the risk factors for placental abruption?
Previous abruption Multiple pregnancy Trauma e.g. RTC Domestic violence ECV Threatened miscarriage earlier in the pregnancy Pre-eclampsia HTN Multiparity Previous C-section Non-vertex presentation Smoking Cocaine/amphetamine use Thrombophilia Intra-uterine infectons Polyhydramnios
What are the symptoms of placental abruption?
PV bleeding
Abdominal pain - usually continuous
Uterine contractions
What are the signs of placental abruption?
“Woody hard” abdomen
Shock
Foetal distress
Abnormal CTG
What investigations would you perform for placental abruption?
None, it is a clinical diagnosis.
What is the management for placental abruption?
ABCDE
Delivery: if foetus is alive then can ARM or perform a C-section. If the foetus becomes distressed then C-section
If the foetus has died then a vaginal delivery unless haemorrhage is massive then a C-section may be indicated to control bleeding.
What are the risk factors for vasa praevia?
IVF pregnancy
Multiple pregnancy
Bilobate or succenturiate placenta
Second-trimester placenta praevia
What is vasa praevia?
It is where one of the branches of the foetal umbilical vessels lies in the membranes and across the cervical os
What is the presentation of vasa praevia?
Painless vaginal bleeding, rupture of membranes and foetal bradycardia
What investigations would you perform for vasa praevia?
It is usually found at the 20-week anomaly scan
Transvaginal USS and colour doppler can also show it
What is the management for vasa praevia?
Antenatal monitoring to detect compression and an elective C-section delivery.
Emergency C-section if there is PROM, vaginal bleeding continues or foetal status is non-reassuring
What are the complications of vasa praevia?
It may be accompanied by other placental abnormalities e.g. velamentous insertion which increases the risk of foetal haemorrhage when foetal membranes rupture
What is the definition of primary PPH?
EBL >500ml from the genital tract within 24 hours of delivery
Minor is =/< 1000mls, major is >1000mls
What is the aetiology of primary PPH?
4 T's Tone Tissue Trauma Thrombin Uterine atony most common
What are the risk factors for primary PPH?
APH Placenta praevia Placental abruption Multiple pregnancy Polyhydramnios Macrosomia Pre-eclampsia/pregnancy induced hypertension Grand multiparity Previous PPH BMI >35 Asthia ethnic origin Age >40 Uterine abnormalities Maternal anaemia LSCS Retained placental Mediolateral episiotomy IOL Labour >12 hours Maternal pyrexia in labour
What are the symptoms for primary PPH?
Continuous bleeding which fails to stop after the delivery of the placenta
What are the signs of primary PPH?
Loss of >1000mls may be accompanied by clinically apparent shock (increased HR, low BP)
What is the management of primary PPH?
ABCDE
Monitoring of FBC, crossmatch and coagulation studies
Establish cause
Tone: bimanual uterine compression, ensure bladder is empty, oxytocin 5 units by IVI, ergometrine 0.5mg slow IVI/IM (unless HTN), carboprost 0.25mg IM (can have up to 8 times), misoprostol 1000mg PR, balloon tamponade, B-lynch suture, bilateral ligation of uterine arteries, bilateral ligation of internal iliac arteries, selective arterial embolisation, TAH
What are the complications of primary PPH?
Hypovolaemic shock DIC AKI Liver failure Acute ARDS Death
How can primary PPH be prevented?
Active management of the third stage of labour with prophylactic oxytocics.
What is the definition of secondary PPH?
Abnormal bleeding from the genital tract, from 24 hours after delivery to 6 weeks postpartum
What is the aetiology of secondary PPH?
Infection - endometritis
Retained products of conception
What are the risk factors for infection (and therefore secondary PPH)?
LSCS Prolonged rupture of membranes Severe meconium staining in liquor Long labour with multiple examinations Manual removal of the placenta Very low or high maternal age Low socioeconomic status Maternal anaemia Prolonged surgery GA Internal foetal monitoring
What are the symptoms of secondary PPH?
Fever Abdominal pain Offensive smelling lochia Abnormal PV bleeding Abnormal vaginal discharge Dyspareunia Dysuria General malaise
What are the signs of secondary PPH?
Fever
Rigors
Tachycardia
Tenderness of the suprapubic area and adnexae
Elevated fundus which feels boggy in RPOC
What investigations would you perform for secondary PPH?
FBC Blood cultures MSU High vaginal swab - check for gonorrhoea and chlamydia USS Speculum examination
What is the management for secondary PPH?
SEPSIS pathway if suspected
For endometritis: Abx, RCOG guideline for sepsis after pregnancy recommends tazocin
For RPOC: D&C with antibiotic cover
What are the risk factors for postnatal depression?
History of mental health problems Psychological disturbance during pregnancy Poor social support Poor relationship with partner Baby blues Recent major life event Unplanned pregnancy Unemployment Not breastfeeding Antenatal parental stress Antenatal thyroid dysfunction Longer time to conception >/= 2 children Substance misuse
What is the presentation of postnatal depression?
Low mood Loss of enjoyment and pleasure Anxiety Disturbed sleep Loss of appetite Poor concentration Low self-esteem Worthlessness and feelings of guilt Low energy levels Loss of libido Thoughts of death/suicidal thoughts
What is the management of postnatal depression?
General principles: empowerment, communication, the wider family environment, adolescents (keep in mind the issues surrounding adolescent mothers)
Mild-moderate: consider facilitated self-help strategies
Mild depression with a history of severe depression: consider an antidepressant
Moderate or severe depression: high-intensity psychological intervention e.g. CBT, antidepressant treatment or both
What are the risk factors for shoulder dystocia?
DM Foetal macrosomia Maternal obesity IOL Prolonged labour Too much oxytocin Previous shoulder dystocia Instrumental delivery
What are the anatomical causes of shoulder dystocia?
Uterine problems with contraction
Foetal lie
Shape of the maternal pelvis
How is shoulder dystocia identified?
The head has delivered but the shoulders will not, the head is pulled back tightly against the vulva (turtle sign). The mothers pelvis constricts the baby’s chest and there is often cord compression leading to asphyxiation and acidosis
What is the treatment for shoulder dystocia?
McRoberts position McRoberts manoeuvre Rubin manoeuvre Woodscrew manoeuvre Mother on all fours +/- woodscrew again Maternal syphsiotomy Push head back in and LSCS Break clavicle
What is it important to do after a shoulder dystocia delivery?
DOCUMENT
Check for Erb’s palsy
Umbilical gases for acid-base balance
What is the classification for ectopic pregnancy?
Tubal 95% - ampullary, isthmic, fimbrial, interstitial
Others <5% - cervical ovarian scar
Heterotopic - ectopic and intrauterine pregnancies
What are the risk factors for an ectopic pregnancy?
History of infertility Assisted conception History of PID Endometriosis Previous pelvic/tubal surgery Previous ectopic pregnancy IUCD in situ Smoking Prior induced abortion
What are the symptoms of an ectopic pregnancy?
Pain Amenorrhoea PV bleed Could be asymptomatic Shoulder tip pain Collapse
What are the signs of an ectopic pregnancy?
Acute abdomen - peritonism, guarding, tenderness at adnexae, distension
Cervical excitation
Shock
What investigations would you perform for an ectopic pregnancy?
Pregnancy test Transvaginal USS Serum progesterone and serum bhCG Laparoscopy FBC, group & save/crossmatch
What is the management for an ectopic pregnancy?
Expectant - need strict selection criteria and to monitor closely
Medical - methotrexate 50mg/m2 (75-90mg usually) if the patient is clinically stable, has minimal symptoms, the ectopic is <3cm, no foetal cardiac activity, no haemoperitoneum and hCG <3000IU
Surgical - laparoscopy/laparotomy to perform a salpingectomy or salpingotomy
Anti-D immunoglobulin for rhesus negative mothers with a confirmed or suspected ectopic pregnancy
What are the female causes of subfertility?
30% anovulation 25% tubal blockage 5% cervical problem 5% sexual problem 30% defective implantation due to an endometrial problem e.g. polyps PCOS is the commonest cause
What investigations would you perform for subfertility?
Female:
Day 2-5 profile of FSH, LH, TSH, prolactin, testosterone, mid-luteal progesterone, rubella and chlamydia screening, anti-mullerian hormone (ovarian reserve) and HSG
Male: Semen analysis (after patient has abstained from sexual intercourse for 3-4 days), karyotyping if suspect a genetic cause
What is the management for subfertility?
Medical: clomifene and hCG injection, metformin may be added in women with PCOS and BMI >25 who are unresponsive to clomifene. Gonadotrophins, dopamine agonists (ovulatory disorders secondary to hyperprolactinaemia)
Surgical: tubal surgery, laparoscopic surgery for endometriosis or surgical correction of epididymal blockage
Assisted conception: intrauterine insemination (women must have patent fallopian tubes), IVF (women must have functional ovaries), ICSI
What is the pathogenesis for Rhesus Disease of the Newborn?
There are rarely any problems during primary exposure but subsequent pregnancies result in large amounts of anti-D maternal antibodies being produced. They can cross the placenta and fix onto foetal RBCs which then become recognised as “foreign” by the foetal immune system and haemolysed
What is the presentation of Rhesus Disease of the Newborn?
Antenatally, the first indication of the condition is the presence of anti-D antibodies in the mother as detected by the indirect Coombs test. All Rhesus negative women have this test.
Antenatal: foetal anaemia, hydrops foetalis
Postnatal: hydrops foetalis, early jaundice, kernictus, cutaneous haemopoietic lesions, hepatosplenomegaly, coagulopathy, thrombocytopenia and leukopenia
What investigations would you perform for Rhesus Disease of the Newborn?
Indirect Coombs test
Antenatal USS
Foetal blood sampling
Postnatally: cord or neonatal blood for low Hb, raised reticulocytes, low platelets, direct coombs test +ve group, high serum bilirubin. Monitor SBR 4 hourly until the rate of rise is known.
What is the management for Rhesus Disease of the Newborn?
In utero: if blood sample confirms anaemia, intrauterine blood transfusion with O-neg packed red cells. Best done at 18/40
Postnatally: Start high risk infants on intensive phototherapy whilst awaiting SBR Hb result. If SBR >100micromol/L then prepare for exchange transfusion
Supportive treatment
What is the prophylaxis for Rhesus Disease of the Newborn?
Rh anti-D IgG given to RhD-ve mothers after the birth of a Rh+ve foetus
What are the different types of cord prolapse?
Overt - umbilical cord can slip past the presenting part and present into the cervix or descend into the vagina
Occult - where the umbilical cord lies along the presenting part
Cord presentation - where the cord can be felt to prolapse between the presenting part +/- membrane rupture
What are the risk factors for cord prolapse?
Prematurity Foetal congenital abnormality Second twin Multiparity Low birth weight Breech Oblique, transverse and unstable lie Cephalopalvic disproportion Pelvic tumours Low lying placenta Polyhydramnios Macrosomia High foetal station Long umbilical cord
What are the signs of a cord prolapse?
A cord prolapse may occur with no outward physical signs and a normal foetal heart trace.
Abdo examination - an ill-fitting or non-engaged presenting part should alert one to the possibility of a cord prolapse.
Overt - cord can be seen protruding
Occult - cord is rarely felt on VE
What is the management for cord prolapse?
Treat as an acute obstetric emergency
Overt: O2 4-6L/min, place mother in knee-chest position or head down left-lateral position and apply upwards pressure against the presenting part. Emergency LSCS ASAP! Only proceed with NVD if it’s imminent. Resuscitation available for the foetus.
Occult: Put mother in left-lateral position, if the foetal heart rate returns to normal then allow labour to continue with mother receiving O2 and continuous foetal monitoring. If FHR is abnormal then proceed to emergency LSCS
